Antibiotic | Organisms Covered | Dose | Notes |
|---|---|---|---|
Ampicillin | Gram-positive organisms (Streptococcus spp.) Susceptible Escherichia coli Listeria monocytogenes | Empiric treatment for early- or late-onset (age >72 hrs) sepsis:
Treatment >48 h:
| |
Piperacillin | Pseudomonas aeruginosa Enterococcus spp. Other Gram-negative enteric and anaerobes PCN-susceptible Staphylococcus spp. Streptococcus spp. |
| Moderate CSF penetration |
Penicillin GK | GBS Treponema pallidum | GBS meningitis:
Other GBS infections: 200,000 units/kg/d divided every 6 h | |
Nafcillin | Methicillin-sensitive Staphylococcus aureus | Non-CNS infections:
Meningitis:
| Cleared primarily by the liver → monitor LFTs on treatment Can cause interstitial nephritis → monitor renal function weekly on treatment Can cause bone marrow suppression → monitor CBC weekly on therapy |
Vancomycin | Aerobic and anaerobic Gram-positive cocci and bacilli Methicillin-resistant S. aureus (MRSA) Coagulase-negative staphylococci Clostridium difficile Bacillus spp. Ampicillin-resistant Enterococcus |
| Only 10%–15% of serum concentration enters CSF. Optimal serum concentration:
|
Gentamicin, amikacin, tobramycin | Broad Gram-negative bacillus coverage Synergistic against S. aureus, GBS, L. monocytogenes, enterococci | Gentamicin
Tobramycin
Amikacin
| CSF penetration depends on meningeal inflammation. Monitor peak and trough levels, as these antibiotics can cause nephrotoxicity and ototoxicity. |
| |||
Clindamycin | Gram-positive cocci Anaerobes (including Bacteroides fragilis) |
| Poor CSF penetration Cleared by the liver → monitor LFTs while on therapy |
First-generation cephalosporins (cefazolin, cephalexin) | Susceptible Staphylococcus, Streptococcus, and pneumococci | Cefazolin:
| Poor CSF penetration |
Second- generation cephalosporins (cefuroxime, cefoxitin, cefotetan, cefprozil) | Same as first generation plus Haemophilus influenzae E. coli Citrobacter Klebsiella Enterobacter cloacae | Improved activity over first-generation against β-lactamase–producing organisms Little data in neonates, so use is limited | |
Third-generation cephalosporins (ceftriaxone, cefdinir, ceftazidime, cefotaxime, cefixime) | Gram-negative enterics H. influenzae Neisseria gonorrheae Neisseria meningitidis | Cefotaxime:
Ceftazidime:
| Ceftazidime can be used for adequate coverage of Pseudomonas aeruginosa. Ceftazidime, cefotaxime, and ceftriaxone all achieve good CSF penetration. Ceftriaxone displaces bilirubin from albumin, raising serum levels of free unconjugated bilirubin → not recommended for use in neonates except in treating gonococcal infection in nonjaundiced neonates. In jaundiced neonates, use cefotaxime. |
Ceftriaxone
| |||
Macrolides (azithromycin) | Gram-positive bacteria MRSA Neisseria spp. T. pallidum Chlamydia trachomatis Bordetella pertussis | Infants <6 mo:
| |
Oxazolidinone (linezolid) | Resistant Enterococcus faecium, S. aureus, Streptococcus pneumoniae | Neonates:
Preterm infants:
| Use must be approved by infectious disease service |
Carbapenems (meropenem) | Aerobic and anaerobic Gram-positive and Gram-negative bacteria | 0–7 d postnatal age:
>7 d postnatal age:
| Use must be approved by infectious disease service Good CSF penetration Resistant organisms: Burkholderia cepacia, E. faecium, Stenotrophomonas maltophilia |
Age of Infant | Most Common Etiologies | Empiric Therapy | Length of Therapy |
|---|---|---|---|
<1 mo | L. monocytogenes, GBS, Enterobacteriaceae (E. coli) | Ampicillin and cefotaxime OR ampicillin and gentamicin If Gram-negative bacilli, use cefotaxime instead of gentamicin, as gentamicin has poor CSF penetration. | 14–21 d: GBS, L. monocytogenes 21 d: Enterobacteriaceae (cefotaxime + aminoglycoside) |
1–3 mo | GBS, S. pneumoniae, N. meningitidis, H. influenzae, Enterobacteriaceae | Ampicillin and cefotaxime | 10–14 d: S. pneumoniae 7 d: N. meningitidis 7–10 d: H. influenzae |
>3 mo | S. pneumoniae, N. meningitidis, H. influenzae, above neonatal pathogens | Cefotaxime or ceftriaxone Add vancomycin if possible PCN-resistant S. pneumoniae until susceptibilities return | Same as above |
Consider less common forms of neonatal meningitis if index of suspicion is high based on history or physical examination findings: viral (HSV (meningoencephalitis), enterovirus, VZV), tuberculosis, fungal, and noninfectious causes (eg, leukemic infiltrates).
- Neurologic: seizures, lethargy, irritability, decreased tone; full fontanelle
- Fever (>38°C) or hypothermia (more common in preterms)
- Respiratory distress: grunting, tachypnea, nasal flaring
- Poor feeding
- Diarrhea, vomiting
- Apnea
- Premature rupture membranes, maternal fever/infection, fetal hypoxia, birth trauma, galactosemia (E. coli sepsis), low birth weight, preterm infants (<37 wk)
- CBC, blood culture, UA with microscopy/culture, LP (cell count, protein, glucose, Gram stain/culture), PCR studies if indicated (HSV, enterovirus, VZV, LCMV)
- Viral surveillance cultures, if indicated: conjunctiva, nasopharynx, rectum
- Culture any cutaneous lesions concerning for HSV, VZV:
- Classic finding of ↓ CSF glucose, ↑ CSF protein, and pleocytosis: seen more with early GBS meningitis, Gram-negative meningitis and late Gram-positive meningitis; may also be suggestive of viral meningitis (eg, enterovirus).
- Only if all three parameters are normal does LP provide evidence against infection; no single CSF parameter can exclude the presence or absence of meningitis in neonates.
- Bacterial meningitis commonly causes CSF pleocytosis >100 WBC/μL, predominantly polymophonuclear cells evolving to lymphocytes.
- Viral meningitis in neonates: picture may be similar but with a less dramatic pleocytosis.
- Maternal investigation: If possible, send placenta for pathology and, if indicated, cultures/PCR.
- MRI/CT: to identify focal areas of infection, infarction, hemorrhage, edema, hydrocephalus, or abscess formation. Consider with focal neurologic abnormalities, persistent infection, or clinical deterioration.
- Eye exam may be helpful to evaluate for chorioretinitis.
- Classic finding of ↓ CSF glucose, ↑ CSF protein, and pleocytosis: seen more with early GBS meningitis, Gram-negative meningitis and late Gram-positive meningitis; may also be suggestive of viral meningitis (eg, enterovirus).
CSF Component | Weight (grams) | Postnatal Age (days) | ||
|---|---|---|---|---|
0-7 | 8-28 | 29-84 | ||
†Erythrocytes/mm3 | ≤1000 1001–1500 | 335 (0–1780) 407 (0–2450) | 1465 (0–19,050) 1101 (0–9750) | 808 (0–6850) 661 (0–3800) |
Leukocytes/mm3 | ≤1000 1001–1500 | 3 (1–8) 4 (1–10) | 4 (0–14) 7 (0–44) | 4 (0–11) 8 (0–23) |
Neutrophils (% of total leukocytes) | ≤1000 1001–1500 | 11 (0–50) 4 (0–28) | 8 (0–66) 10 (0–60) | 2 (0–36) 11 (0–48) |
‡Glucose (mg/dL) | ≤1000 1001–1500 | 70 (41–89) 74 (50–96) | 68 (33–217) 59 (39–109) | 49 (29–90) 47 (37–76) |
*Protein (mg/dL) | ≤1000 1001–1500 | 162 (115–222) 136 (85–176) | 159 (95–370) 137 (54–227) | 137 (76–260) 122 (45–187) |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
